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Follicular Unit Hair Grafting
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Over the past 2 ½ years, the author has performed 495 hair transplant procedures. Follicular unit grafting was the technique utilized in 94% of these cases. Of these 465 cases, 417 were performed on men, 48 on women. The indication for treatment for the great majority of cases was pattern baldness, with all degrees of hair loss treated. Other indications included the repair of scarring and hairline distortion from prior facial plastic surgery, and trichotillomania.
The number of grafts placed in a single follicular unit grafting procedure ranged from 250 to 3,115 with the great majority of cases receiving between 1600-1800 grafts. The transplanted density approached 30-35 follicular units per cm2, with higher densities achievable, when desired, in areas where 2, 3, and 4 hair grafts were placed closer together. Determining the percentage of transplanted hairs that grew is very difficult to assess, because of the inability to distinguish transplanted from original hairs. It is the impression that this percentage increased over the first 6 months that the follicular unit grafting procedure was performed, reflecting the improvement in technique and accumulated experience of the surgeon and assistants. Currently, it can be estimated that over 90% of transplanted hairs grow.
Telogen effluvium, or the early loss of transplanted hairs, occurred in over 90% of hairs. Regrowth of the transplanted hairs occurred as soon as 8 weeks post-procedure. In almost all cases where patients applied 5% minoxidil once daily starting at 1 week post-procedure, regrowth occurred before 3 months. Most patients who did not reliably apply minoxidil post-procedure required 3 to 4 months before regrowth of hair.
Complications were minimal, and results were exceptionally rewarding. The criteria of an excellent result include both technical and artistic factors. It is the technical factors that are affected by the specific technique utilized, and therefore are the relevant factors to assess. These technical factors include: absence of recipient site skin alterations such as hypopigmentation, dimpling, and scarring; ability to reliably place 1 hair grafts along the anterior-most hairline with 2, 3, and 4 hair grafts placed progressively behind to create a subtle feathering zone; an overall natural, non-grafted appearance; and absence of donor site scarring. Based upon these criteria, excellent to outstanding results are achieved in nearly all patients. Patients are almost universally satisfied with the results of their procedure.
Complications at times did occur, but nearly all could be considered minor and usually resolved with time. These complications included: lower percentage of hair growth than expected in 7 patients, requiring the performance of an additional small procedure to replace the hairs that didn't grow; prolonged scalp erythema of longer than 3 weeks in 1 patient; superficial cellulitis in 2 patients that required a change in antibiotic but that resulted in normal hair growth; excessive "shock" to the original existing hairs in 2 patients, leaving them somewhat thinner for the first 6 to 10 weeks until these hairs started to regrow, and in all cases resulting in a return to full density; and 1 case of partial thickness skin breakdown of less than 4 cm in diameter in the anterior central forelock region after a procedure of 3115 grafts performed in an active cigarette smoker which was subsequently treated with a scar repair and further grafting.
Patient 1: 34 y.o. male, with Class 4 Hamilton-Norwood hair loss. Treated with a single procedure of 2200 follicular unit grafts.
Patient 2: 54 y.o. male, with Class 6 hair loss. Treated with a single procedure of 2300 follicular unit grafts.
Follicular unit grafting is an enormously satisfying procedure to perform, with high patient satisfaction and very acceptable results. From a technical perspective, the procedure requires a highly motivated team of assistants, capable of dissecting grafts under a microscope for prolonged periods of time. Switching from traditional micro/minigrafting to the follicular unit grafting required adding 3 assistants to the original 3 that had been sufficient to perform cases without microscopic dissection. Training of these new assistants was facilitated by the use of the microscope because it is easier to visualize the individual follicular units, an observation made by others as well.(14)
With experience and the feedback provided by follow-up of patients, refinements in technique have been made. Extensive dissection of all surrounding non-hair bearing skin has been reduced. By including a slightly larger cuff of tissue around the follicles, hair growth seems to have improved. This is likely due to the greater protection of the follicle from damage from dessication and trauma during the planting the graft. Dessication appears to be the greatest enemy to graft survival, and numerous precautions are taken to prevent it. The most important step is storing grafts in chilled saline from the time of donor site harvest to implantation. To further assure good hair growth, saline rather than hydrogen peroxide is used to clean the scalp of blood and other debris during the procedure.
Several steps help to minimize scarring in both the donor and recipient site regions. Donor site scarring (width of scar greater than 3 mm) is avoided by suturing under minimal tension with a running 3-0 Prolene placed superficial to the follicles. Keeping the donor strip no wider than 10 to 12 mm minimizes closure tension; the strip can always be made longer to obtain the greatest number of grafts. In addition, a donor site location at or cephalad to the plane along the top of the ears reduces the risk of wide scar formation by avoiding the action of the occipitalis muscle on the healing wound edges.. Hypopigmentation and scarring of the recipient site region is avoided by minimizing the amount of skin around the grafts, but does not prevent the maintaining of a small cuff of subcutaneous fat to improve graft viability, as discussed above. Dimpling of the skin around transplanted grafts is prevented by inserting the grafts to a depth such that its skin is sitting just above, and not flat or below, the surface of the surrounding skin.
The advantages of follicular unit grafting are many. The most important is the natural appearing results with an absence of scalp scarring. Graft yield is significantly increased, while trauma to already existing hairs in areas being transplanted is reduced by the smaller recipient sites that are needed for the smaller grafts. Other advantages of smaller grafts include the more rapid healing, and the ability to place grafts closer together.
Another particular advantage of follicular unit grafting is that the technique does not commit the patient to subsequent procedures in the future, unless further density and/or more extensive coverage is desired. The natural but thin look achieved after just one procedure will be adequate for a large percentage of patients. This makes the procedure ideal for all degrees of hair loss, from early thinning to advanced hair loss, where only a forelock is to be transplanted.(15)
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